A VISIT FROM DR. STEAD “What This Patient Needs is a Doctor”

be coming to the hospital as a visiting professor. Stead’s time was limited and so he chose to confine himself to simply making teaching rounds with one of the medical teams. This was somewhat disappointing to those who expected a lecture focused on one of Stead’s many areas of expertise such as congestive heart failure, syncope, shock, peripheral vascular disease, or sarcoidosis. Nevertheless, they also knew that Stead was a renowned bedside teacher. Teaching rounds were always patient centered at the bedside at Duke as well as at UPMC and so an entourage of residents, interns and medical students proceeded out of the medical conference room with Dr. Stead and down the hall towards the patient’s bedside.

At this point, Dr. Stead (in typical Steadian fashion) turned around and asked in his mellow Southern drawl, “Fellows, what are we going to talk about this morning?” That of course meant what was the patient’s tentative diagnosis or admitting problem. The senior resident on the team had chosen a patient with sarcoidosis and hypercalcemia. He naturally thought this would be a very interesting case to discuss. “Dr. Stead, we are going to have the intern present a patient with sarcoidosis and an elevated blood calcium level.” “Well, that sounds very interesting,” said Dr. Stead, “Always liked sarcoidosis, very interesting systemic disease. There is still a whole lot to learn about that disease, but I don’t think I want to talk about that today. What else ya got?” At this the residents, interns, and students stared in disbelief. Had they heard him right? He didn’t want to talk about that! Was he serious? Stead looked around at the shocked crowd and then focused his gaze at the senior resident. “What else ya got?” “Well. we are also prepared to present a case of streptococcus viridans endocarditis.”

“That’s very interesting too” Stead replied. “My colleague, Dr. Paul Beeson was one of the first persons to use penicillin to successfully treat streptococcus viridans endocarditis and my famous mentor, Dr.

Soma Weiss wrote the best description of the natural history of endocarditis. That case involved a medical student by the name of Alfred Reinhart who died from streptococcus viridans endocarditis. Mr. Reinhart died in 1931. Dr. Weiss reported his case about 10 years later. That paper is a medical classic. I recommend it to all of you. But except for this, I really don’t wish to discuss endocarditis. What else do you have?” At that, the resident went through a litany of cases, hesitating now and then to see if the great Dr. Stead was interested. Stead gave a negative reply to all of them and then asked, “Who is your least interesting patient?” The senior resident looking surprised and confused said haltingly, “That would be Bessie. She’s at the far end of the hall and is waiting for nursing home placement. She has an ankle ulcer, a decubitus ulcer, and some cognitive issues.” “Dementia?” “Yes, sir, we think it is a senile form of dementia.” “Well, let’s go see this lady” and then Dr. Stead quickly led the team to the room at the end of the unit and the bedside of a lady we will call “Bessie Jones.”

After the intern presented the patient’s history and physical examination, Dr. Stead commented that “you must know this lady pretty well to be calling her by her first name.” Stead then asked the intern several questions regarding Bessie’s social history; where did she live, what was that neighborhood like, where was she born, was she married, did she have children or relatives and if so where did they live, did she get visitors, did she choose a nursing home or is it being assigned? Her team of doctors knew that she had never married; her only local relative was her niece. Her niece visited Miss Jones occasionally. Her nurse was in the room at the time and she replied to Dr. Stead that there was an older man that visited her almost every day from 3 pm to 6 pm. “It would appear then that this man is a close and loyal friend of Miss Jones.” He then looked at the intern and in a very kind and mannerly drawl asked, “don’t you think we should know who this man is and wouldn’t it be nice if the nursing home is easily accessible to him?” “I don’t think you know Miss Jones as well as you should. Let’s see if we can get to know her better.” With that Stead began his own superlative history and bedside examination. Stead first established that her cognitive dysfunction was minimal. She had a bilateral cerumen impaction and couldn’t hear or understand the intern’s “big words”. She replied to Stead’s questions and comments perfectly well as he leaned towards her and spoke into the least blocked ear canal in easily understood language. Stead then commented on how common hearing problems and especially undiagnosed cerumen impaction were mistaken in the elderly for cognitive dysfunction. He established that she was fairly poor and lived in a dangerous neighborhood. The man who visited her was the widower of Bessie’s best friend. They had, sort of, become companions. He lived in a better neighborhood close to the hospital and a few nursing homes. She had to leave school in the 6th grade and had worked for decades as a cleaning lady and she had other nieces and nephews in Virginia where she was born. For years she had visited Virginia every summer but she preferred Pittsburgh.

Then Stead demonstrated his observations on the sacral and ankle ulcers and whether these were purely pressure related or whether venous or arterial ischemia played a role. If arterial ischemia was a factor, a vasodilator might help. If venous stasis was the culprit and arterial circulation was still good, elevating the extremity would help. His conclusion was that venous stasis was a major cause. He then went into a question-and-answer discussion

Continued on Page 18

From Page 17 of the autonomic nervous system in the elderly and how it affects elderly blood vessels and blood flow. Stead gently elevated the legs and noted slight pallor in the nail beds that recovered fairly promptly. The arterial pulses at multiple levels in the lower extremities were normal. He discussed the vascular anatomy of the lower extremities and where the vulnerable sites were located for venous or arterial insufficiency. It was an educational tour de force. More importantly, it directly benefited Miss Jones. She understood the situation better, became more involved in her care, and complied better with frequent turning to alleviate pressure on the ulcers. Elevation of the leg and pressure dressings helped to improve the venous circulation without impairing arterial inflow. An ENT specialist removed all the cerumen from her ear canals. Her family in Virginia was willing to contribute some money towards a short nursing home stay. She was placed in a facility that was on a bus route easily accessible to her friend. Her ulcers eventually healed. The house staff was in awe of what Stead had just done. One of the interns asked him, “Dr. Stead, why did you do that? Why did you want to see the least interesting patient?” Stead smiled and in his easy North Carolina country style replied, “You fellas are all over that sarcoidosis case, same thing with that fellow with endocarditis. Those folks will get good care because you boys are all up to snuff on that stuff. Me, I’m worried about the old lady at the end of the hall. Plus, just say for me I think you will find that when you get to know the patient well and think deeply about their clinical problems all patients are interesting and deserve the best attention we can give them.” This ended the most important educational experience of my medical career.

“There are lots of M.D.s, but there are too few doctors!”

—Dr. Eugene A. Stead

References

Lazlo, John M.D., Neelon, Francis A. M.D., “The Doctor’s Doctor, A Biography of Eugene A.Stead Jr., M.D.”, Carolina Academic Press, Durham, North Carolina, 2006.

Stead, E.A. Jr. M.D., “What This Patient Needs is a Doctor”, Duke University Medical Center Press, Durham, North Carolina, 1978.

Tischler, Peter V, “Soma Weiss, Alfred Reinhart, and the care of the patient”, Perspect Biol Med 2010 Winter;53(1):75-86.

Lamb, Michael G. M.D., Personal Recollections and Notes.